My insurance unexpectedly sent me partial reimbursement for top-surgery

The title says it all, but here’s the details:  Prior to surgery, I put a lot of effort into trying to figure out what I might be able to get reimbursed for.  I was on the phone with customer service for a long time one day; I scoured my insurance’s webpage; I tried to figure out codes and what they mean; my therapist called multiple times on my behalf.  I oscillated between feeling hopeful I might get partial coverage, and being convinced that there was no chance.

Ultimately it seemed like there was no chance.  I found a promising document at one point called, “Gender Reassignment Surgery Medical Policy,” followed by criteria to prove it is medically necessary.  Then I was told that that applies to some insurance policies with my insurance company, but my particular policy excludes this coverage, and that was the bottom line.

Still, people told me that it’s against the law to deny coverage, on a state by state basis, and my state should cover it.  I paid out of pocket, first for the surgeon’s fees in advance, and then for the surgical center, the day of.  After the fact, I asked my surgeon’s office to send me an itemized bill of what I’d paid for, and I submitted that to my insurance company, without much hope.  I figured it’d get denied, then I’d appeal and take it as far as I could.  Maybe I’d get some advice from my local gay alliance, etc.

About 2 weeks later, I got a piece of mail.  I didn’t open it because I didn’t care to read the bad news.  My spouse and I were leaving for vacation last Wednesday, and I figured I’d better open it before we left.  In case there was some deadline for appealing it.  I opened it up, and it was a check for $2,800.09!!!!  I yelled at my partner about it, the excitement of it, which must have been jarring because I almost never yell.  What an amazing way to start our trip!

That’s 47% of the surgeon’s fees (including 100% of the accommodations – staying at the surgeon’s guest room!)  I really could not believe it – either the person on the receiving end wasn’t paying attention at all, or they knew exactly what it was and had some strong personal beliefs of what should get to be covered!!

Now I’m just deciding if I should also get an itemized bill from the surgical center and try to get more money back…  Maybe I don’t want to push my luck…

It really paid off to just try, even though I didn’t believe anything would come of it!

Here’s a post I wrote earlier on this topic:
In February, I wrote GID: exclusion for top surgery coverage

The Re-imagination Program

I’ve been using Androgel, daily, for over a year and a half now.  And I’m just now getting a full understanding about how the prescription & insurance industrial complex works as it relates to me continuing to get what I need.  Here are a few experiences that, each taken separately, are small, but as a collection of anecdotes, are kinda mind-boggling:

– My first doctor initially tried to sway me toward a different product, Fortesta, telling me I could save big, and handed me a discount card I could activate.  I went through all the hoops only to learn I was not eligible because I am not male.  When I came back to him with this, he changed my prescription to Androgel without further discussion.

– Although I made clear to him that I was aiming to be on a very low dose, and see what happens from there (like 1-2 pumps), he wrote the script out as 4-6 pumps daily.  This led me to be able to get 2 bottles at one time for $25.  This amount lasted me for 4 months.  At $6.25 per month, I wasn’t about to speak up about the inaccuracy!

– The prescription wording has changed over time (and between two doctors), and I’ve felt confused as to how that equates to how much I’m getting and how much I’m paying.  I’ve paid $25 for 2 bottles together, $50 for two bottles together, and even $50 for only one bottle at one point.  I guess I assumed it fluctuated in price.  I thought I was paying per bottle.

– I’m not paying per bottle.  I’m paying per month.  My payment, I finally found out, should be $25 per month (not too bad!), but somehow I’ve continued to avoid even having to pay that much.  I also have been able to store some bottles in reserves (which helps me feel much more secure since most of my visits to the pharmacy have led to some sort of questioning, calling of my doctor office, etc.  Not for anything personally about me, but because of how the script was written out.)

Basically, while talking to my insurance company (using the pharmacy’s phone) last week, I learned that all that matters is how the script is written.  Testosterone is a controlled substance.  I always have to pick up the prescription at my doctor’s office and show a picture ID.  I can never get a refill (although my doctor has tried!)  If the doctor writes the dose out as 1-2 pumps per day, the higher amount is factored in.  If it’s 4-6 pumps, it’s 6 pumps, even if I’m only actually using one.  No one seems concerned about whether the amount correlates to what I’m doing.  I can get a 30 day supply, a 60 day supply, or a 90 day supply.  I’d prefer the 90 day because it means I don’t have to go as frequently.  But if it’s entered as a 30 day supply, it’s 1/3 of the price.  And no one actually seems concerned with whether that translates into how frequently I go to the pharmacy.  Interestingly, I could pay a whole lot more to get the amount I use, or I could pay a whole lot less to get more than the amount I use.  I don’t understand this logic, but I do finally understand this system.

When I was told I’d be paying $50 for one bottle and would have to come back in 2 months with a new prescription, for my 2nd bottle (due to the wording of the script) last week, I argued with that.  The pharmacist got me on the phone with my insurance (which led to me finally grasping how this works).  I realized the only way around it was to get the script re-written by my doctor.

I asked the pharmacist if I could get a discount card for Androgel.  This is called “The Restoration Program.”  Due to my experience with the Fortesta discount card, I wasn’t holding my breath.  The pharmacist got me started and then handed the phone to me to complete the activation process with an Androgel representative.  He was friendly and smooth.  I was asked a lot of questions:  name, address, email, phone number, etc.  I was asked if I’ve read all the terms and conditions.  Since I had just been handed the booklet with mass amounts of fine print 2 minutes prior, I just said, “yes.”  I was then asked, “Are you MALE?”  He said the word, “male,” in such a harsh, abrasive tone; all customer-serviceness left his voice.  I paused for a good long while.  Repeated the question back to him.  Said, “No.”  Said, “I’m not legally male; if there is any other criteria under which someone could be male, I’m interested in that.”  But his helpfulness was long gone.  I felt mildly humiliated; he just kept grinding it in that he could do nothing further for me.

My jaded brain (during a conversation with my partner’s jaded brain, haha) decided that men are rewarded for using Androgel because the company is trying to promote a specific type of patient for their product.  Rugged, middle-aged, robust and vigorous.  Masculine.  Diagnosed with low testosterone, just needing a boost.  Just take a look at the pics of men on their website:
Androgel website

I am nothing like the men on the website.  However, I am just as worthy of being eligible for a discount program!  I would call it “The Re-imagination Program.”  Testosterone has certainly aided me in re-imagining who I am and what I can do / who I can become.

I told the pharmacist I wasn’t eligible.  He acted surprised, but my jaded brain decided he already knew.  The next day, I called my doctor’s office; asked for the prescription to be written the way it had previously been written.  Got a call back that it was all set; ready for pick-up.  Picked up the prescription, went back to the pharmacy, got my 3 month supply for $50.  Anticipating more hassles in the future…